to download msiaf

1

MANIPUR STATE ILLNESS ASSISTANCE FUND

---------------------

(MSIAF)

(Amended till 20.02.2013)

2

CONTENTS PAGES

1. INTRODUCTION 3

2. FUND INVOLVEMENT 4

3. FORMS 5

ANEXURES

I. Memorandum of Association of MSAN 6 - 8

II. Articles of Association of MSAN 7 - 12

III. Eligibility Criteria for MSIAF 13

IV. Orders by the Governor 14

V. The List of Categories of Treatments eligible under MSAN 15 - 17

VI. Manipur State Arogya Nidhi Application Form 18

VII. Manipur State Arogya Nidhi Estimate Certificate Form 19

VIII. Manipur State Arogya Nidhi Affidavit 20

IX. Income Certificate 21

3

INTRODUCTION

Manipur State Illness Assistance Fund (MSIAF) is a fund, which provides

financial assistance to the poor patients who are suffering from life threatening

disorders & diseases, for treatment in Government Hospitals of Manipur. The Fund is

proposed to be a significant step for bridging the gap and reach of economically

backward section of society to quality healthcare. The fund is managed by an

autonomous Society known as Manipur State Illness Assistance Fund Society. The

Society is registered under the Manipur Societies Registration Act, 1989 (Manipur Act

1 of 1990).

MSIAF has been set up by suitably modifying the guidelines of the Rashtriya

Arogya Nidhi (RAN) scheme managed under the Union Ministry of Health and

Family Welfare according to local needs and conditions. MSIAF would essentially

provide financial assistance to patients living below the poverty line (BPL) to receive

medical treatment at Jawaharlal Nehru Institute of Medical Sciences (JNIMS), Imphal

and Regional Institute of Medical Sciences (RIMS), Imphal, at present. The financial

assistance to such patients would be released in the form of a “one-time grant”, which

shall be released to the Medical Superintendent of the Hospital in which the treatment

is being received.

The MSAN/MSIAF is governed by a Memorandum of Association and related

Articles of Association.

4

FUND INVOLVEMENT

The Manipur State Illness Assistance Fund (MSIAF), which is managed by an

autonomous Society known as Manipur State Arogya Nidhi (MSAN), derives its

revolving fund from three sources. These sources are as follows:-

1. Grants from the Government of Manipur;

2. Grants from the Government of India, Ministry of Health & Family

Welfare; and,

3. Grants/donations from philanthropic individuals, organizations and

other voluntary donors to pledge support and contribute to the funds of

the Society in cash or kind. All contributions thus made to this fund

shall be exempted from payment of income tax under Section 80-C of

Income Tax Act, 1961 as is the case for Rashtriya Arogya Nidhi (RAN).

The Manipur State Exchequer has to contribute annually to MSAN/MSIAF in

the form of Non-Plan expenditure as is done for RAN. The Ministry of Health &

Family Welfare, Government of India, will release Grant-in-Aid annually to the extent

of 50% of the contributions made by the State subject to a maximum of Rs 200.00

lakhs in case of Manipur. This dictates that to get the maximum GIA from the Centre,

the State Exchequer has to contribute Rs 400.00 lakhs annually as Non-Plan

expenditure towards MSAN/MSIAF.

--------------

5

FORMS

1. Manipur State Arogya Nidhi Application Form (Annexure VI)

2. Manipur State Arogya Nidhi Estimate Certificate Form (Annexure VII)

3. Manipur State Arogya Nidhi Affidavit (Annexure VIII)

4. Income Certificate (Annexure IX)

6

MANIPUR STATE ILLNESS ASSISTANCE FUND (MSIAF)

MEMORANDUM OF ASSOCIATION

Name of the Society: (1) The name of the autonomous Society shall be

MANIPUR STATE ILLNESS ASSISTANCE FUND SOCIETY.

Registered Office : (2) The registered office of the above Society shall remain in

Imphal, and at present is at the following address:-

Directorate of Health Services, Lamphelpat, Imphal -

795001.

Aims and Objectives: (3) The aims & objectives for which the Society is established

are:-

a) To raise a revolving fund in the name of “Manipur State

Illness Assistance Fund (MSIAF)” to be managed by this

Society;

b) To utilize MSIAF solely for the one-time assistance of

poor patients who are in the need of undergoing treatment

for major ailments.

c) To motivate philanthropic individuals, organizations and

other voluntary donors to pledge support and contribute to

the funds of the Society in cash or kind.

d) To organize social, cultural and motivational events for

raising such resources.

e) To liaise with health and other functionaries in the State

such as District Hospitals, CHCs, PHCs, PHSCs, etc. for

providing better health care;

7

f) To undertake information, education and communication

(IEC) activities relevant to the basic aims and objectives

of the Society;

g) To acquire, purchase or otherwise own or take on lease or

hire in Manipur or outside, temporarily or permanently,

buy any movable or immovable property necessary or

convenient for the furtherance of the objects of the

Society;

h) To monitor and control proper utilization of funds or

materials received from the Governments from time to

time for the functions of the MSIAF;

i) To frame rules and regulations for day to day execution of

the Society‟s activities and to amend the Memorandum of

Association from time to time, if necessary in consultation

with the State Government;

j) To appoint or employ on contract basis any person for the

purposes of the Society and to pay them such salary or

wages as may be determined by the Management

Committee;

k) To undertake all such lawful acts as are conducive or

incidental to the attainment of the objectives of the

MSIAF;

All the incomes, earnings, accrued interests, moveable and immoveable

properties of the Society shall be solely utilized and applied towards the promotion of

its aims and objectives only, set forth in the Memorandum of Association, and no

profit there from shall be paid or transferred directly or indirectly by way of

dividends, bonuses, profits in any manner whatsoever to the present or past Member

of the Society. The Members shall not claim on any moveable or immoveable

properties of the Society and make no profits, whatsoever, by virtue of their

membership.

8

Management Committee of MSIAF:

(4) The Members of the Management Committee to whom the management of the

Society is entrusted are as follows (amended vide order No. No. 25/2/2010-M of 19th

December, 2012):-

(i) Chief Secretary, Govt. of Manipur. – Chairman

(ii) Principal Secretary (Health) -- Member Secretary

(iii) Director, Health Services, Manipur -- Member

(iv) Director, Family Welfare, Manipur -- Member

(v) Representative of Finance Department -- Member

a) Subscription: There is no subscription fee for membership.

b) Cessation of Membership: The Members shall be Members as long as they hold the

office by virtue of which they are Members of MSIAF.

Screening Committee of MSIAF:

(5) The Screening Committee constituted in the Directorate of Health Services for

Medical Re-imbursements of Govt. employees would be adopted as the Screening

Committee of MSIAF. Moreover, a District Level Screening Committee in all 9 (nine)

Districts has been constituted with the following Members:-

a) Deputy Commissioner of the District - Chairman

b) CMO of the District - Member Secretary

c) CEO/ADC or Zilla Parishat of the District - Member

d) Medical Supdt. of the Dist Hospital - Member

------------------

9


ARTICLES OF ASSOCIATION

RULES AND REGULATIONS

1. The “Manipur State Illness Assistance Fund (MSIAF)” would be managed as an

autonomous society known as “Manipur State Illness Assistance Fund Society”.

2. In these Rules & Regulations, unless there is anything repugnant to the subject or

context:-

a) „Act‟ means the Manipur Societies Registration Act, 1989 (Manipur Act 1 of

1990);

b) „Chairman‟ means the Chief Secretary, Government of Manipur;

c) „Management Committee‟ means the Management Committee of the Society;

d) „Society‟ means the Manipur State Illness Assistance Fund Society;

h) „Year‟ means the year commencing from 1st April ending with 31

st March of

the financial year.

3. The Society would manage the MSIAF to provide one-time assistance on re-

imbursement basis to poor patients living in Manipur for treatment of major

ailments at JNIMS, RIMS and other Govt. Hospitals.

4. (i) The sources of MSIAF shall be as follows:-

a) Grants from the Government of Manipur;

b) Grants from the Government of India;

c) Grants/donations from philanthropic individuals, organizations and

other voluntary donors to pledge support and contribute to the funds of

the Society in cash or kind.

(ii) All donations to this fund shall be made in the name of „Manipur State

Illness Assistance Fund Society‟. A receipt shall be issued to every donor.

(iii) All donations received shall be unconditional and irrevocable.

10

(iv) A bank account in the name of the Society shall be operated jointly by the

Commissioner (Health), Govt. of Manipur, and the Director of Health

Services, Manipur, for the purposes detailed in the aims and objectives of

the Society.

(v) The accrued interest from this Fund shall be used solely for the furtherance

of the purposes detailed in the aims and objectives of the Society. The

accrued interest on deposits of the Fund shall be construed as

income/receipts of the fund and would be exempt from income-tax.

(vi) The nature of this Fund shall be revolving and can be carried over to the

succeeding year for the purposes detailed in the aims and objectives of

the Society.

(vii) Eligibility criteria for assistance under MSIAF shall be as given in

Annexure I.

(viii) A list of ailments eligible under MSIAF is at Annexure II.

(ix) Application for assistance under MSIAF shall be submitted in the

prescribed format as at Annexure III.

(x) Procedure for Sanction:-

a) Applications should be submitted to the Director of Health Services, Manipur,

in the prescribed format. The report of the Screening Committee, indicating the

expenditures eligible for re-imbursement under MSIAF, would be submitted to the

Member Secretary, Management Committee of MSIAF. The Member Secretary would

process for convening a meeting of the Management Committee at least once a month

for consideration of the proposals for approval. The payment for approved cases

would be released by Account Payee Cheques.

b) The decision of the Management Committee shall be final.

c) Financial aid so granted shall be a one-time grant only with an upper limit of

Rs 1.00 (Rupees One Lakh) only.

d) Cases once approved and sanctioned cannot apply again.

11

5. (i). The chairman would have the power to co-opt any other person on the

Management Committee meeting if the presence of such person is considered useful.

(ii) The Management Committee shall meet once a month for considering the

application recommended by the Screening Committee. Meeting may be held to

discuss the general functions of the Society, audit accounts, expenditure and receipts,

and any other subject.

(iii) An extra-ordinary meeting of the Management Committee may be called by the

Chairman to consider any special matter or resolution.

(iv) Since the Members are ex-officio members, they shall be members till they hold

charge of the office concerned. Their successors, by virtue of the office held, will

replace them as members automatically.

(v) The Chairman shall preside over the meetings. In the absence of the Chairman, one

of the Members elected from amongst those present shall preside over the meeting.

(vi) The minimum quorum for conducting any meeting shall be a simple majority of

the total members of the Management Committee. In the absence of quorum, the

meeting shall stand adjourned by two hours. If there is no quorum even then, the

meeting shall be adjourned until further notice.

(vii) A minimum of 3 days notice should be given for an ordinary and a minimum of

24, hours for an emergency meeting.

(viii) Decision of the Management Committee shall be on the basis of consensus of

the majority of the Members.

(ix) Proceedings of the meeting of the Management Committee shall be drawn and

circulated by the Member Secretary with the prior approval of the Chairman. All such

proceedings shall be submitted to the Government for approval.

(x) The Director, DHS, shall maintain proper accounts of the fund, and file the same

with the Registrar of Societies along with the list of Members of Governing Body as

per section 13 of the Act, whenever necessary.

12

7. All RTI cases relating to MSIAF shall be settled urgently and judiciously. The

Public Information Officer of MSIAF shall be the Director, Health Services. The

Additional Director, Medical Directorate, shall be the Assistant Public Information

Officer.

8. All provisions under all the sections of the “Manipur Societies Registration Act,

1989 (Manipur Act 1 of 1990)” shall apply to the Society.

----------------------------

13

No. 25/2/2010-M

GOVERNMENT OF MANIPUR

SECTT: HEALTH DEPARTMENT

-------

ORDERS BY THE GOVERNOR, MANIPUR

Imphal, 20th of February, 2013

No. 25/2/2010-M: Consequent upon the State Cabinet Decision taken on

08.02.2013 and in supersession of all previous orders issued in this regard, the

Governor is pleased to revise and modify the Manipur State Illness Assistance Fund

Scheme as follows:-

1) Constitution of a District Level Screening Committee in all 9 (nine) Districts

with the following Members:-

e) Deputy Commissioner of the District - Chairman

f) CMO of the District - Member Secretary

g) CEO/ADC or Zilla Parishat of the District - Member

h) Medical Supdt. of the Dist Hospital - Member

2) A corpus sum of an initial fund of Rs 20.00 lakhs from MSIAF to be deposited

each to JNIMS, RIMS and District CMOs for advance payment and

reimbursement payment to eligible BPL patients.

3) The ceiling of Rs 1.00 lakh per patient is revised to Rs 1.50 lakh.

4) The District Level Screening Committee may approve proposal upto Rs

50,000/- in accordance with the Rules & Regulations of the MSIAF Scheme

and proposal above Rs 50,000/- to Rs 1,50,000/- may be submitted to State

Management Committee for approval.

5) Treatment/Diagnostic Tests in empanelled private Hospitals and Diagnostic

Centres inside & outside the State shall be considered for MSIAF Scheme.

However, advance payment/reimbursement will be limited to the ceiling of the

approved Government rates (CGHS Delhi, 2010 Rates).

By Orders & in the name of the Governor,

Sd/-

(Dr. K. Shyamsunder Singh)

Deputy Secretary, Health

14

Annexure I

ELIGIBILITY CRITERIA FOR MSAN/MSIAF:

1. Patient must be permanent resident of Manipur and has to furnish domicile

proof of residence in Manipur.

2. Patient should belong to a family living “Below Poverty Line” as notified

by the State Government from time to time, and certified by an Officer not

below the rank of Sub-Divisional Officer.

3. Government employees are not eligible under this scheme. However, retired

Govt. Employees are eligible, subject to fulfilling income criteria.

4. Treatment should be from Jawaharlal Nehru Institute of Medical Sciences

(JNIMS), Imphal; Regional Institute of Medical Sciences (RIMS), Imphal;

or other Government Hospitals. Treatment/Diagnostic Tests in empanelled

private Hospitals and Diagnostic Centres inside & outside the State shall be

considered for MSIAF Scheme. However, advance payment/reimbursement

will be limited to the ceiling of the approved Government rates (CGHS

Delhi, 2010 Rates).

5. The patient should be suffering from a major ailment as at Annexure II.

6. The assistance from MSIAF (one-time) would be on re-imbursement basis

and not exceed Rs 1.50 lakh (Rupees One Lakh Fifty thousand).

15

Annexure II

THE LIST OF AILMENTS ELIGIBLE UNDER MSIAF (amended vide Order No.

25/2/2010-M of 25th October, 2012):-

A) Cardiology & Cardiac Surgery:

1. Pacemakers

2. CRT/Biventricular pacemaker

3. Automatic Implantable Cardioverter Defibrillator (AICD)

4. Combo devices

5. Diagnostic Cardiac Catheterization including Coronary Angiography

6. Interventional procedure including Angioplasty, Rota-ablation, BalloonValvuloplasty.

7. ASD, VSD and PDA surgery.

8. Peripheral Vascular Angioplasty, Carotid Angioplasty, Renal Angioplasty

9. Coil Embolization and Vascular plugs

10. Stents including Drug Eluting Stents

11. Electrophysiological Studies (EPS) and Radio Frequency (RF) Ablation

12. Heart surgery for Congenital and Acquired conditions including C.A.B.G

13. Vascular Surgery and all major cardiac surgeries

14. Cardiac Transplantation, etc.

B) Cancer:

1. All forms of cancer

2. Radiation treatment of all kinds

3. Anti-Cancer Chemotherapy

4. Bone Marrow Transplantation- Allogeneic& Autologous

5. Diagnostic Procedures- Flow cytometry/cytogenetic /IHC TumourMarkers, etc.

6. Surgery for cancer patients

7. Catheters, Central lines and Venous access devices.

C) Urology/Nephrology/Gastroenterology:

1.Dialysis and its consumable (Both haemodialysis as well as Peritoneal)

2.Plasmapheresis in acute renal failure

3.Continuous renal replacement therapy in acute renal failure in ICU patients.

4.Vascular access consumables (Shunts, catheters) for Dialysis

5.Renal transplant

6.PCN and PCNL Kits

7. Lithotripsy (for Stones)

8.Disposables/Stents for endoscopic surgical procedures in Urology &Gastroenterology.

D) Orthopedics:

1. Artificial prosthesis for limbs

2. Implants and total hip and knee replacement

3. External fixators

4. AO implants, used in the treatment of bone diseases and fractures

5. Spiral fixation Implant- Pedicle Screws (Traumatic, Paraplegic, Quadriplegic)

6. Implant for Fracture fixation (locking plates & modular)

7. Replacement Hip –Bipolar /fixed

16

8. Bone substitutes

9. Misc. like Polytrauma Patients, Fracture of ankle of femurs, Trochanteric fracture, Spine

fracture dislocations with Paraplegia/ Quadriplegia/unstable spine fractures, Non union

(gap/infected) of long bones, ACL/Meniscus tear with unstable Knees, Malignant bone

tumours, Chronic osteomyelitis of low bones, Pilon fractures of distal tibia, T.B. Spine with

neural deficit, Knee replacement surgery, etc.

E) Surgery: All major surgeries& complications including gynaecological & obstetrical

surgeries.

F) Medicine:

1. Major chronic illness requiring prolonged medications.

2. Acute medical severe problem like: ACS-CAD, Severe Bronchial Asthma, Pulmonary

Embolism, Deep Venous Thrombosis, Severe Pneumonia, Diabetic Ketoacidosis, Acute

CVA.

G) Paediatrics

i) Childhood Malignancies.

ii) Growth Hormone Deficiency.

iii) Hypothyroidism.

vi) Cerebral Palsy.

v) Hepatitis - B

vi) Hepatitis - C.

vii) Chronic Renal Failure & Dialysis.

viii) Diabetes

ix) Thalassemia

x) Chronic Haemolytic Anaemia

xi) Liver Diseases

xii) Aplastic Anaemia

xiii) All life threatening serious ailments

xiv) Shunts for Hydrocephalus

H) Ophthalmology

Cataract & its treatment, Glaucoma & its treatment, Ocular & Orbital tumours, Retinal

Diseases – a). Diabetic Retinopathy, b). Retinal Detachments, Vitreous Diseases – a).

Macular Oedema, b). Hypertensive Retinopathy, Optic atrophy and its investigations,

Squint and its treatment, & Ptosis surgery.

I). Dentistry

i. Tooth Extraction.

ii. Scaling and root planning.

iii. Gingival Surgery.

iv. Root canal treatment.

v. Restoration of Dental caries

vi. Minor Surgery.

vii. Major Surgery (Mandibulectomy, Maxillectonry etc.)

J). All ailments requiring ICU & ICCU.

17

K). ENT: Chronic Rhino- Sinusitis, Acute Rhino- Sinusitis, Acute otitis media, Acute and Chronic

suppurative otitis media, Otogenic brain abscess, Acute and Chronic laryngitis, Cancer

of larynx, oral cavity, sinuses, Nasopharynx and ears, Polyposis, Sinus Surgeries, Ear

Surgeries, Thyroplasty, Hearing Aids, Ossicular Prosthesis, Artificial voice prosthesis and

Cochlear implant.

L)Neurology/Neurosurgery:

Brain Tumors, Head Injuries, Intracranial aneurysms, AVMs, Spinal tumors,

Degenerative/Demyelinating diseases, Stroke, Epilepsy, Movement Disorders, & Neurological

Infections.

M) Endocrinology:

Hormonal replacement for life long therapy for Diabetes, Hypopituitarism, Hypothyroidism,

GH deficiency, Cushings syndrome, Adrenal insufficiency, Endocrine surgery.

N) Mental Illness:

i. Organic Psychosis; acute & chronic

ii. Functional psychosis including Schizophrenia, Bi-polar disorders, delusional disorders

& other acute polymorphic psychosis

iii. Severe OCD, Somatoform disorders, eating disorders

iv. Developmental disorders including autisms, spectrum disorders and severe

behavioural disorders during childhood

O) Drugs:

Immunosuppressive drugs, Anti D, Anti-Hemophilic Globulin, Erythropoietin, blood & Blood

products/Plasma for patients of burns, Liposomal Amphotericin, Peg Interferon, Ribavirin, CMV

treatment (IV Gancyclovir, valganciclovir), Voriconazole, Anti-rejection treatment (ATG, OKT3),

Treatment for post-transplant viral infection, any life supporting drugs, Immunoglobulin for AIDP (GB

syndrome) & Myasthenia Gravis, Anti viral, anti fungal, Wilson dis: Penicillamine A, Botulinum A toxin

injection for spasticity, Baclofen for spasticity.

P)Investigations:

All blood profiles, Ultra-sound, Doppler studies, Radio-nucleotide scans, CT

Scan,Mammography, Angiography for all organs, M.R.I, E.E.G, E.M.G, Urodynamicstudies, Cardiac

Imaging- Stress Thallium & PET, CT Coronary angiographic, Cardiac MRI, Investigation for CMV, BK

Virus, TMT, Echocardiography, Psycho diagnostics, Neuropsychological assessments, IQ assessments,

Blood tests for serum lithium, carbamazepine, valproate, phenytoin and other similar medications,

CSF studies screening for substances or abuse/toxicology, Hormonal assay for endocrine disorders,

Biochemical assay for Metabolic Syndrome including lipid profile, glucose profile, Viral load assay for

chronic HBV/HCV, Arterial Blood Gas analysis, ENG, PURE TONE AUDIOGRAM, IMPEDANCE,

AUDIOMETRY, BERA.

-----------------------------------------------------

18

Annexure III

APPLICATION FORM FOR FINANCIAL AID FROM


1. Name of the patient (in Block Letters) :

2. Age :

3. Father/Husband’s Name :

4. Residential address :

(Attach-photocopy of

Ration card/Voter‟s Identity Card

/Birth Certificate (in case of minor)

5. Name of disease; since when suffering :

& treatment required.

6. Name of the Hospital from where :

treatment was taken

7. Amount of financial assistance required :

(Certificate A or B, as applicable, to be attached in ORIGINAL)

8. Monthly income of family from all sources :

(Income/BPL Certificate to be enclosed in original as per

Annexure IV).

9. Two passport size photographs of the patient to

be enclosed (one should be pasted on Income/BPL Certificate

and the other on this application form).

10. Whether the applicant has taken such assistance

from any other sources ; if so, give details :

11. Whether the applicant has taken the assistance

from MSIAF earlier; if so, details thereof :

It is certified that the information furnished above is true to the best of my knowledge & belief and that

I am in no position at all to arrange for/provide funds for the purpose stated above. I also declare that neither

my parents nor I are employees of the Central/State Govt. or a local body.

Checklist:-

1. Certificate A/B

2. Income/BPL Certificate (Annexure IV)

3. Affidavit (Annexure V)

Date: Signature of the applicant/patient

(In case patient is a minor, signature of father/mother).

19

Annexure IV

INCOME CERTIFICATE (performa)

On the basis of the affidavit filed/documents produced by

Shri/Smt/Ms_____________________________________________ _____________

.____________________________________________________________________

Son/Daughter/Wife of ___________________________________________________

residence of ___________________________________________________________

__________________________________ before the undersigned and in view of the

verification and enquiry report submitted by ________________________________,

the total family‟s income from all sources of Shri/Smt/Ms.

_______________________________________________________ assessed to be/ is

Rs.____________________ _______________________per month.

Concerned SDO/ADC/DC.

20

Annexure V

AFFIDAVIT (Performa)

I, __________________________________________s/o, d/o, w/o _______________

_________________________ _______________________________________________ r/o

___________________________________________________________________________

do hereby solemnly affirm and declare as under :-

1. That, I/my wife/husband/mother/father/son/daughter namely __________________

_______________________________________________ has been suffering from ________

____________________________________ disease and is under treatment at ____________

________________________________ Hospital for which the approximate expenditure shall

be to the tune of Rs. __________________________________________________________

as certified by the hospital authorities.

2. That, my total family income is Rs. __________________________ per month.

The source of income is by way of ____________________________________________

(Give specific details).

3. That, I am not in a position to bear the expenses of the treatment.

4. That, I know that to make a false statement is an offence punishable under relevant

Act and law and whatever is stated above is true to the best of my knowledge and belief.

DEPONENT

VERIFICATION :-

Verified at …………………………………… on this ……………………...…………. day of

…………………………….. and that the contents of this affidavit are true and correct to the

best of my knowledge and belief.

DEPONENT

WITNESSES:-

Sl.No. Name & Address Signature (with date)

1.

2.

21

CERTIFICATE – A

(To be completed in the case of patients who are not admitted to Hospital for treatment)

Certificate granted to Mr/Mrs/Miss ____________________________________________________

wife/son/daughter of Shri/Smt ______________________________________________________________

employed in the _________________________________________________________________________.

I, Dr. _____________________________________________________________________ certify

(a) That, I charged and received Rs __________________________ for ___________________________

consultation on _________________ (date to be given) at my consulting room/at the residence of the

patient.

(b) That, I charged and received Rs __________________________ for administering ________________

___________________________________________________________________________________

(c) That, the injections administered were/were not for immunizing of prophylactic purpose.

(d) That, the patient has been under treatment of ______________________________________ Hospital/

my consulting room and that the under mentioned medicines prescribed by me in this connection

were essential medicines for the recovery/prevention of serious deterioration in the condition of the

patient. The medicines are not stocked in the _______________________________________ Hospital

for supply to private patients and do not include proprietary preparations for which cheaper substances

of equal therapeutic value are available nor preparations which are primarily food, toiletries nor

disinfectants.

Name of Medicines Price in Rs.

1. __________________________________ ____________________

2. __________________________________ ____________________

3. __________________________________ ____________________

(e) That, the patient is/was suffering from ___________________________________________________

and is/was under my treatment from ______________________ to _____________________________

(f) That, the patient is/was not given pre-natal or post-natal treatment.

(g) That, the X-Ray, Lab Tests, etc. for which an expenditure of Rs _______________________________

was incurred was incurred and were undertaken on my advice at _______________________________

(name of Hospital/Laboratory).

(h) That, I referred the patient to Dr ___________________________________________ for specialist

consultation and that the necessary approval of the __________________________________________

(name of the CMO of the District) as required under the Rules was obtained.

(i) That, the patient did not require/required hospitalization.

Signature & Designation

Of the Medical Officer.

22

CERTIFICATE – B

(To be completed in the case of patients who are admitted to Hospital for treatment)

Certificate granted to Mr/Mrs/Miss ___________________________________________________________

wife/son/daughter of Shri/Smt _________________________________________________________________

Part-A

I, Dr. _____________________________________________________________________ hereby certify

(j) That, the patient was admitted to the Hospital on the advice of

________________________________________________________ (name of the Medical Officer/on my

advice.

(k) That, the patient has been under my treatment at _________________________________________ and that

the above mentioned medicines prescribed by me in this connection were essential to the recovery/prevention of

serious deterioration in the condition of the patient. The medicines are not stocked in the

_______________________________________________ Hospital for supply to private patients and do not

include proprietary preparations which are primarily foods, toiletries or disinfectants.

Name of Medicines Price in Rs.

1. __________________________________ ____________________

2. __________________________________ ____________________

(l) That, the injections administered were/were not for immunizing or prophylactic purposes.

(m) That, the patient is/was suffering from ____________________________________________ and under my

treatment from ______________________ to _____________________________

(n) That, the patient is/was not given pre-natal or post-natal treatment.

(o) That, the X-Ray, Lab Tests, etc. for which an expenditure of Rs ____________________________ was

incurred was incurred and were undertaken on my advice at _______________________________ (name of

Hospital/Laboratory).

(p) That, I called on Dr ___________________________________________ for specialist consultation and that

the necessary approval of the __________________________________________ (name of the Medical

Superintendent) as required under the Rules was obtained.


Of the Medical Officer-in-charge of the case at the Hospital.

Part – B

I certify that the patient has been under my treatment at the ___________________________________ Hospital

and that the service of the special nurse of which an expenditure of Rs __________________________ was

incurred, vide bills and receipts attached, were essential for the recovery/prevention of serious deterioration in

the condition of the patient.


Of the Medical Officer-in-charge of the case at the Hospital.

COUNTERSIGNED

Medical Superintendent

____________________________________ Hospital

I certify that the patient has been under the treatment at the minimum which were essential for the patient‟s

treatment.

Medical Superintendent

____________________Hospital

Place __________________________ Date _________________________

Note: Certificate not applicable should be struck off.

to download msiaf

Documents